Medical Billing

Tuesday, September 2, 2014

DME is equipment that can withstand
repeated use, is primarily used for a medical purpose, and is not generally
used in the absence of illness or injury. Examples include hospital beds,
wheelchairs, and oxygen delivery systems. Medicare will cover medical supplies
that are necessary for the effective use of DME, as well as surgical dressings,
catheters, and ostomy bags. However, Medicare will only cover DME and supplies
that have been ordered or prescribed by a physician. The order or prescription
must be personally signed and dated by the patient's treating physician.

DME suppliers that submit bills to
Medicare are required to maintain the physician's original written order or
prescription in their files. The order or prescription must include:

o the beneficiary's name and full
address;

o the physician's signature;

o the date the physician signed the
prescription or order;

o a description of the items needed;

o the start date of the order (if
appropriate); and

o the diagnosis (if required by
Medicare program policies) and a realistic estimate of the total length of time
the equipment will be needed (in months or years).

For certain items or supplies,
including supplies provided on a periodic basis and drugs, additional
information may be required. For supplies provided on a periodic basis,
appropriate information on the quantity used, the frequency of change, and the
duration of need should be included. If drugs are included in the order, the
dosage, frequency of administration, and, if applicable, the duration of
infusion and concentration should be included.

Medicare further requires claims for
payment for certain kinds of DME to be accompanied by a CMN signed by a
treating physician (unless the DME is prescribed as part of a plan of care for
home health services). When a CMN is required, the provider or supplier must
keep the CMN containing the treating physician's original signature and date on
file.

Generally, a CMN has four sections:

Section A contains general information on the patient,
supplier, and physician. Section A may be completed by the supplier.

Section B contains the medical necessity justification
for DME. This cannot be filled out by the supplier. Section B must be
completed by the physician, a non-physician clinician involved in the care
of the patient, or a physician employee. If the physician did not
personally complete section B, the name of the person who did complete
section B and his or her title and employer must be specified.

Section C contains a description of the equipment and
its cost. Section C is completed by the supplier.

Section D is the treating physician's attestation and
signature, which certifies that the physician has reviewed sections A, B,
and C of the CMN and that the information in section B is true, accurate,
and complete. Section D must be signed by the treating physician.Signature
stamps and date stamps are not acceptable.

By signing the CMN, the physician
represents that:

o he or she is the patient's
treating physician and the information regarding the physician's address and
unique physician identification number (UPIN) is correct;

o the entire CMN, including the
sections filled out by the supplier, was completed prior to the
physician's signature; and

o the information in section B
relating to medical necessity is true, accurate, and complete to the best of
the physician's knowledge.

Saturday, August 30, 2014

September 1st 2014 is the US labor
day, The Department of Labor's Unemployment Insurance (UI) programs provide
unemployment benefits to eligible workers who become unemployed through no
fault of their own, and meet certain other eligibility requirements.

In the United States unemployment benefits
generally pay eligible workers between 40-50% of their previous pay. Benefits
are generally paid by state governments, funded in large part by state and
federal payroll taxes levied against employers, to workers who have become
unemployed through no fault of their own. This compensation is classified as a
type of social welfare benefit.

Eligibility :

In order to receive benefits, a person must
have worked for at least one quarter in the previous year and have been
laid-off by an employer. Workers who were temporary or were paid under the
table are not eligible for unemployment insurance. If a worker quits or is
fired they are not eligible for UI benefits. There are five common reasons a
claim for unemployment benefits are denied: the worker is unavailable for work,
the worker quit his or her job, the worker was fired, refusing suitable work,
and unemployment resulting from a labor dispute. In practice, it is only
practical to verify whether the worker quit or was fired.

Generally, the worker must be unemployed
through no fault of his/her own although workers often file for benefits they
are not entitled to; when the employer demonstrates that the unemployed person
quit or was fired for cause the worker is required to pay back the benefits
they received. The unemployed person must also meet state requirements for
wages earned or time worked during an established period of time (referred to
as a “base period”) to be eligible for benefits. In most states, the base
period is usually the first four out of the last five completed calendar quarters
prior to the time that the claim is filed. Unemployment benefits are based on
reported covered quarterly earnings. The amount of earnings and the number of
quarters worked are used to determine the length and value of the unemployment
benefit. The average weekly in 2010 payment was $293.

Whether the provider, Novitas Solutions, or
another entity identifies an overpayment, the overpaid funds must be
reimbursed to Novitas Solutions in one of the following ways:

A. Immediate Recoupment as a Means to Repay Medicare Debt - Part A and Part B

The
immediate recoupment process is for providers who have received an
overpayment demand letter and are actively billing Medicare. Immediate
recoupment is not an alternative for sending a voluntary refund to
Medicare.

You may elect to have your overpayment(s) repaid through the immediate
recoupment process and avoid paying by check or waiting for the standard
recoupment that begins automatically on day 41 from the date of the
initial demand letter. A request for immediate recoupment must be
received by Medicare in writing no later than 16 days from the date of
the overpayment demand letter. You must specify whether you are
submitting:

1. A one-time request for all invoices included in the current overpayment demand letter and all future overpayments

2. A request for all invoices included in only the current overpayment demand letter received

The
immediate recoupment process is optional and for your convenience.
You may find savings in check printing and postage since you are
requesting to have your Medicare overpayment(s) withheld from your
future Medicare claim payments.

Any principal balance remaining after the initial immediate recoupment
attempt will continue to accrue interest and continue in the recoupment
process and other collection activities until the overpayment is
satisfied. You may fax your immediate recoupment request directly to
the following fax numbers:

Part A fax line: (412) 802-1836

Part B PA/NJ/MD/DC/DE providers may fax to: (717)-728-8722

Part B AR/CO/LA/MS/NM/OK/TX providers may fax to: (717)-728-8728

As stated above, there are two immediate recoupment request options available:

3. A one-time request for all invoices included in the current overpayment demand letter and all future overpayments

4. A request for all invoices included in only the current overpayment demand letter received

Note:

If you select option 1 above, for future overpayments the immediate
recoupment process will automatically begin on day 16 from the demand
letter dates (assuming the provider has paying claims). The 16 day
timeframe allows for the 15 day rebuttal period.

If you select option 1 above, you can later fax or mail a written
request to Medicare to discontinue participation in the immediate
recoupment process at anytime. Allow Novitas Solutions, Inc. 10
business days from receipt to stop the immediate recoupment process.

If you select option 2 above, please note that the immediate recoupment
process will occur at the demand letter level through our current
process which will not allow offset to begin until day 16 from the
demand letter date (assuming the provider has paying claims). The 16
day timeframe allows for the 15 day rebuttal period.

A
request for immediate recoupment must be in writing and may be
submitted by fax or regular mail. We do not currently offer the option
for you to email us your request. Novitas Solutions, Inc. preferred
method is to recommend utilization of the fax process to insure
efficiency, timeliness, and to decrease costs. Please refer to the fax
numbers listed above including separate fax numbers for Medicare Part A
versus Medicare Part B. Your request for immediate recoupment must
include the following when submitting your request:

Your name and contact phone number (include area code)

Your Provider Transaction Account Number (PTAN)

Your National Provider Identification (NPI)

Your Provider signature or CFO’s signature authorizing the request

The Overpayment Demand Letter number located on the 1st page, at the right top of page

Identify which option you are requesting.

Your request must specifically state you understand you are waiving
potential payment of interest pursuant to Section 1893(f)(2) for
overpayments. Such interest may be payable for certain overpayments
reversed at the Administrative Law Judge level or subsequent levels of
appeal (935 Overpayments).

Medicare is secondary to all accident related claims. Beneficiaries may
not choose which of these claims will be paid by the automobile
insurance and which claims will be paid by Medicare. Providers should
submit all accident related claims to the automobile insurance before
submitting them to Medicare. To avoid late claim filing, claims may be
submitted to Medicare even though payment has not been received from the
automobile insurer. In addition, conditional payment can be made by
Medicare if 1) the automobile insurance will not pay promptly (within
120 days); or 2) due to physical or mental incapacity, the beneficiary
fails to meet the claim filing requirements of the automobile insurer.
Conditional payments are made on the condition that the beneficiary will
reimburse Medicare if payment is later made by the automobile insurer.

If the automobile insurance benefits are exhausted, Medicare requires a
statement of exhaustion from the automobile insurer. The itemized
statement must include: the dates of service paid and the actual
provider who was reimbursed. Note: Claim processing will be denied
without this information.

Providers should complete item 10 of the CMS 1500 claim form if the
services are related to an automobile accident. If there is information
on our files which indicates that a beneficiary has been involved in an
automobile accident, the claim will suspend for manual review. If the
details referenced on the claim are not sufficient information to
process the claim, a questionnaire will be sent to the beneficiary. If a
response is not received from the beneficiary within 45 days, the claim
will be denied.

The BCRC contractor became responsible for
updating the Medicare MSP files, answering general MSP questions or
responding to COB concerns. MSP data may be updated, as necessary, based
on additional information received from patients, providers, attorneys,
or third parties. Development may be required in order to confirm the information.

Black Lung Benefit Act of 1973, It is USA
government program, The Black Lung Benefits Act (BLBA) provides monthly
payments and medical benefits to coal miners totally disabled from
pneumoconiosis (black lung disease) arising from employment in or around the
nation's coal mines. This Act also provides monthly benefits to a miner's
dependent survivors if pneumoconiosis caused or hastened the miner's death. The
Division of Coal Mine Workers' Compensation (DCMWC), within the U.S. Department
of Labor Employment Standards Administration's Office of Workers' Compensation
Programs (OWCP), adjudicates and processes claims filed by coal miners and
their survivors under the BLBA.

Medicare and BLBA

Medicare is secondary for beneficiaries who have
medical benefits under the Federal Black Lung Program. Medicare is secondary
only for services provided for the treatment of lung conditions caused by
mining. Claims for beneficiaries entitled to benefits under the Federal Black
Lung Program may suspend for manual review. If the diagnosis or services
reported on the claim are not related to the black lung condition, Medicare is
primary and the claim will be released for final processing.

For some beneficiaries entitled to the Federal Black Lung Program, the coal
mine operator is responsible for medical benefits. In these cases, providers
should submit the claims to the coal mine operator or its Workers' Compensation
plan for processing.

Monday, August 25, 2014

Modifier 24
24 Modifier Unrelated Evaluation and Management Service by the Same
Physician During a Postoperative Period: Physician may need to indicate
that an evaluation and management service was performed during a
postoperative period for a reason(s) unrelated to the original
procedure.

An E/M service can be coded with modifier 24 to indicate a visit in the
postoperative period that is unrelated to the original procedure
(surgery). This modifier is not valid when coded with surgeries or other
types of services. It is not appropriate for modifier 24 to be coded
with diagnostic tests performed in the postoperative period. These are
not part of the global surgical allowance and are always considered
separately.

In most cases, diagnosis codes that apply to the E/M service are
different from the diagnosis codes indicated on the original procedure.
However, in rare circumstances, the diagnoses are the same, but the
services are unrelated; if so, this information should be documented
with the claim, either in the narrative field on electronic claims or on
an attachment with paper claims.

Hospital visits by the surgeon during the same hospitalization as the
surgery are considered related to the surgery; however, separate payment
for such visits can be allowed if one of the following conditions
applies:

* Immunotherapy management furnished by the transplant surgeon.
Immunosuppressant therapy following transplant surgery is covered
separately from other postoperative services. That is, postoperative
immunosuppressant therapy is not part of the global fee allowance for
the transplant surgery. This coverage applies regardless of the setting.

* The surgeon provides critical care for a burn or trauma patient.
* The diagnosis is unrelated to the original surgery.

Outpatient visits during the postoperative period are allowed during a
global fee period if the claim documentation demonstrates that the visit
is for a diagnosis unrelated to the original surgery. Use modifier 24
in this situation.

Office visits during the postoperative period are not covered unless
they are submitted with modifier 24 to indicate they are unrelated to
the surgery. Modifier 24 is primarily for use only by the surgeon. A
different diagnosis code may be sufficient to show the procedure is
unrelated to the surgery; however, it may not be required. Documentation
submitted should fully explain how the E/M service is unrelated to the
surgical procedure.